Vascularized Fibular Graft Research Articles

One-Barrel Microsurgical Fibula Flap for Reconstruction of Large Defects of the Femur.

Various methods for reconstructing large femur bone defects after tumor resection have been introduced. In this study, we reviewed the clinical outcomes of using a 1-barrel free vascularized fibular graft (FVFG) protected by a lateral locking plate for large femoral defects not involving the knee joint.Between August 2007 and August 2013, we treated 7 patients with large femoral bone defects after tumor resection. The mean age of the patients was 19 years (range, 12-36 years), and 3 were women. All defects were free of infection before the procedure. Femoral bone defects were reconstructed using a 1-barrel FVFG protected by a lateral locking plate. The mean bone defect size was 10.5 cm (range, 6-16 cm). We reviewed clinical outcomes at the last follow-up.All patients survived beyond the last follow-up; the mean follow-up period was 54 months (range, 26-100 months). Two patients sustained stress fractures of the FVFG, but the lateral locking plate protected the fractured graft until in situ bone healing obtained. Mean time to bone union of both host-graft junctions was 24 months (range, 18-31 months). The mean Musculoskeletal Tumor Society score (%) was 85.8% (range, 80-95%).A 1-barrel FVFG protected by a lateral locking plate maintained a stable graft-host bone construct, successfully leading to bone healing, even in cases of stress fractures of the graft, and appears to be a good option for large femur bone defects.

Free vascularized fibula grafting in the operative treatment of malignant bone tumors of the upper extremity: A systematic review of outcomes and complications.

Vascularized bone grafting after tumor resection can be an important component in the treatment of bony neoplasms of the upper extremity. The purpose of this study was to determine the outcomes of free vascularized fibula grafting (FVFG) in the treatment of upper extremity sarcomas. A systematic review of the literature of FVFG used in the treatment of upper extremity sarcomas was performed. A total of 56 studies were included in final analysis. The most common diagnosis was osteosarcoma (35.1%) and the most common recipient site was the humerus (57.3%). FVFG had a median union rate of 93.3%, with the median time to union being 5.0 months. The most common complications were fracture (11.7%), nerve injury (7.5%), infection (5.7%), and hammer toe deformity (3.3%). The reoperation rate was 34.5%. The most commonly reported standardized assessment of clinical outcomes following treatment was the Musculoskeletal Tumor Society Score, which had a median of 80% postoperatively. FVFG in the treatment of malignant bony neoplasms of the upper extremity has a high rate of union and good overall outcomes; however, postoperative complication rates are high. A greater degree of standardization is needed in the reporting of patient-centered outcomes to facilitate future comparative studies.

Intercalary reconstruction of femur after tumour resection: is a vascularized fibular autograft plus allograft a long-lasting solution?

After intercalary resection of a bone tumour from the femur, reconstruction with a vascularized fibular graft (VFG) and massive allograft is considered a reliable method of treatment. However, little is known about the long-term outcome of this procedure. The aims of this study were to determine whether the morbidity of this procedure was comparable to that of other reconstructive techniques, if it was possible to achieve a satisfactory functional result, and whether biological reconstruction with a VFG and massive allograft could achieve a durable, long-lasting reconstruction. A total of 23 patients with a mean age of 16 years (five to 40) who had undergone resection of an intercalary bone tumour of the femur and reconstruction with a VFG and allograft were reviewed clinically and radiologically. The mean follow-up was 141 months (24 to 313). The mean length of the fibular graft was 18 cm (12 to 29). Full weight-bearing without a brace was allowed after a mean of 13 months (seven to 26). At final follow-up, the mean Musculoskeletal Tumor Society Score of 22 evaluable patients was 94% (73 to 100). Eight major complications, five fractures (21.7%), and three nonunions (13%) were seen in seven patients (30.4%). Revision-free survival was 72.3% at five, ten, and 15 years, with fracture and nonunion needing surgery as failure endpoints. Overall survival, with removal of allograft or amputation as failure endpoints, was 94.4% at five, ten, and 15 years. There were no complications needing surgical revision after five years had elapsed from surgery, suggesting that the mechanical strength of the implant improves with time, thereby decreasing the risk of complications. In young patients with an intercalary bone tumour of the femur, combining a VFG and massive allograft may result in a reconstruction that lasts a lifetime. Cite this article: Bone Joint J 2018;100-B:378-86.

Vascularized Fibula Graft Utilizing Full-scale Three-dimensional Bone Model

Vascularized Fibula Graft Utilizing Full-scale Three-dimensional Bone Model

Mandibular Reconstruction with Free Vascularized Fibular Graft.

An iliac block graft is the most commonly used biomaterial for reconstruction following resection of the mandible. Its use has some disadvantages, however, including limitations on the amount of bone that may be harvested, and the subsequent increase in burden on the iliac bone. Therefore, recently, free vascularized fibular grafts have been used as an alternative in some cases. Here, we report the advantages of, and issues related to reconstruction using free vascularized fibular grafts observed at Tokyo Dental College Chiba Hospital. Eight patients undergoing mandibular reconstruction using free vascularized fibular grafts between January 2003 and January 2017 were investigated. Of these, 6 were men, and 2 were women. Age ranged from 38 to 74 years (average, 54 years). Primary diseases comprised malignant tumor in 3 patients, benign tumor in 3, and radiation osteomyelitis of the mandible in 2. The defects were classified as follows according to the CAT system (Condylar Head, Mandibular Angle, Mental Tubercle): 3 cases of Body, 2 of AT, and 1 case each of TT, ATTA, and CATT. The resection range of the mandible was 5-16 cm (average, 10 cm). The single barrel technique was used in 7 cases, and the double barrel technique in 1. In terms of the flap survival ratio, complete engraftment was achieved in 6 out of the 8 cases. Two cases of radiation osteomyelitis of the mandible, with necrosis caused by vascular breakdown after wound infection, were observed, however. While the advantages of mandibular reconstruction by this method include comparatively safe conditions and functional recovery, there were also some problems. It was inappropriate for cases of radiation osteomyelitis of the mandible; those where anti-inflammatory therapy was ineffective; and those where greater resection of the soft tissue was required. Further study is needed to clarify the criteria for selecting this procedure.

EFFICACY OF TWO DIFFERENT RECONSTRUCTION MODALITIES AFTER SURGICAL RESECTION OF MANDIBULAR FIBROUS DYSPLASIA (A CLINICAL STUDY)

Objective: To evaluate efficacy of Nonvascularized bone graft ( NVBG) with bone marrow aspirate concentrate (BMAC) compared with free vascularized fibula graft in reconstruction of mandible after surgical treatment of monostatic mandibular fibrous Dysplasia. Patients and methods: The present study was carried out of three years on 14 patients (8 males & 6 female) ranging from 9- 18 years who had monostatic fibrous dysplasia and need segmental resection and immediate reconstruction. The patients were divided randomly into two equal groups; group I patients grafted with free vascularized fibula graft after segmental resection and group II patients grafted with iliac crest or rib bone graft and injected with BMAC at surgical site after radical excision of lesion. They were selected from those attending the out patient clinic at Faculty of Dental Medicine, Al Azhar University, Assuit branch and the Faculty of Dentistry, in coordination with Plastic Surgery at Suez Canal University Hospital over a period of 4 years (July 2013 –July 2017). Postoperative clinical, radiographic evaluation were performed at 6 month and 12 month till two years after that to assess recurrence of lesion and bone graft density.Results: Both groups was clinically uneventful except two cases in group I and one case in group II .All patients had adequate facial contour, proper facial symmetry and good take post operatively. Radiographic evaluation showed at six month, there was a highly statistically significant difference between two groups. This means that, newly formed bone of group I was significantly denser than group II. At 12 months, the mean of the group I was more than the mean of group II . These showed a difference between means of two groups but this difference was not a statistically significant . Conclusion: Conventional grafting techniques with NVBGs improved by BMAC injection with satisfactory outcomes . Thereby it can be used as alternative modality for free vascularized bone graft in mandibular reconstruction in cases with massive monostatic fibrous dysplasia depend on the size of the lesion

Vascularized fibula with and without extracorporeal radiotherapy for limb salvage surgery in Indian patients

BackgroundReconstruction of segmental bone defects following resection of bone sarcomas is a challenging procedure. Vascularised fibula grafts alone or in combination with extracorporeal radiotherapy and reimplantation of tumor bone have long been established as a method of reconstruction of such defects, with satisfying results. Prompted by paucity of data on Indian patients, we report our experience with vascularised fibula graft for patients undergoing limb salvage surgery for sarcomas of bone. Material and methodsA total of 25 patients underwent the procedure from December 2008 to December 2014. Femur was the commonest site and osteosarcoma was the commonest diagnosis. Intercalary resection was done in 19 patients and arthrodesis in 6 patients. Vascularised fibula was used in combination with extra corporeally irradiated bone in eight patients, and alone in 17 patients. ResultsAll but one limb could be salvaged, and all but three patients had united at final follow up. Combination of extracorporeal radiotherapy and reimplantation with vascularised fibula fared better than vascularised fibula alone in terms of time to union (9.6 months vs 12.2 months) and rate of graft related complications (14.2% vs 62.5%). ConclusionReconstruction with VFG with or without ECRT has a good and predictable functional outcome. Though manageable with active intervention, complications were more commonly seen with vascularised fibula alone than a combination of the two techniques.

Outcomes and Complications of Reconstruction with Use of Free Vascularized Fibular Graft for Spinal and Pelvic Defects Following Resection of a Malignant Tumor.

Following resection of malignant tumors of the spine and pelvis, reconstructive surgeons often face large structural defects. Unlike reconstruction in the extremities, wherein a free vascularized fibular graft (FVFG) is a highly utilized option for segmental osseous reconstruction, there are limited data on the use of an FVFG in the spine and pelvis. The aim of this study was to review our institution's experience with reconstruction with use of an FVFG following oncological resection in the spine and pelvis. We reviewed 24 cases involving the use of an FVFG in reconstruction of segmental osseous defects of the spine and pelvis following oncological resection from 2000 to 2015. The cohort consisted of 12 male and 12 female patients with a mean age of 37 years and a mean follow-up of 5 years. Fifty-four percent of the reconstructions were spinopelvic or sacropelvic. The overall 2, 5, and 10-year rate of survival was 76%, 55%, and 37%, respectively. With regard to disease-free survival, the overall 2, 5, and 10-year rate was 81%, 72%, and 48%. The overall rate of union was 86%, with a mean time to union of 7 months. Complications were common, with 83% of the patients sustaining at least 1 postoperative complication. Following the procedure, the mean Musculoskeletal Tumor Society rating was 53%. An FVFG provides a durable means of reconstruction of osseous defects in the spine and pelvis. Although patient function was acceptable following these large reconstructions, the rate of postoperative complications was high. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Vascularized Fibular Strut Autografts in Spinal Reconstruction after Resection of Vertebral Chordoma or Chondrosarcoma: A Retrospective Series.

Margin-free en bloc resection is the best medical practice for primary vertebral chordoma and chondrosarcoma. Spinal reconstruction following total spondylectomy requires reconstructive interbody graft (allograft, devascularized autograft, vascularized autograft, or cage constructs) and instrumentation. An important consideration when choosing grafts and instrumentation is the durability and the long-term success of the fusion without subsidence. To evaluate the potential use of vascularized fibular autograft as a reconstructive strategy after en bloc resection. We present a series of 16 patients who underwent spondylectomy for primary vertebral chordoma or chondrosarcoma with reconstruction using a vascularized fibular autograft and anterior/posterior instrumentation between January 2011 and April 2014. We report postoperative neurological outcome, 6-mo rates of fusion and graft subsidence, and other complications. Two patients passed away prior to 6-mo follow-up, and 1 patient was lost to follow-up. The mean follow-up time for the remaining 13 patients was 32 mo. Of these patients, 9 (69%) had evidence of fusion on the 6-mo follow-up computed tomography (CT) scan. Of the 4 patients who did not fuse, 2 had undergone surgery for new tumor diagnoses, 1 for hardware failure, and 1 for graft nonunion. Two patients (15%) had eventual graft subsidence along with hardware failure. Vascularized fibular strut grafts are a viable method for reconstruction following spondylectomy. We present the largest series of patients to date utilizing this technique. Further comparative studies examining vascularized grafts vs nonvascularized grafts or metallic cage constructs will be important in choosing the best reconstructive strategy.

An intramedullary nail coated with antibiotic and growth factor nanoparticles: An individualized state-of-the-art treatment for chronic osteomyelitis with bone defects

Among various infections, chronic osteomyelitis is one of the most challenging in terms of treatment. This infection is more common among patients with open fractures and those who have undergone elective orthopedic procedures. The treatment of osteomyelitis requires high antibiotic doses and an aggressive and multifaceted surgical approach. The use of parenteral antibiotics alone, without debridement, is not sufficiently effective, due to the formation of sequestra and the low vascularity of the affected area. The surgical options available for patients with chronic osteomyelitis include sequestrectomy, curettage, and intramedullary reaming, although these procedures usually result in bone defects that require further surgical intervention. Polymethyl methacrylate or calcium phosphate beads, impregnated with antibiotics, are commonly placed in such cases; however, this option has several disadvantages, including the need for future removal of cement, uncontrollable local release of antibiotics, and the need for broad-spectrum agents. The resulting bone defects also require additional treatments involving vascularized fibula grafting, intramedullary nails, use of techniques like Masquelet and Ilizarov, and even soft tissue transfers. All of these methods have certain limitations, such as the eventual requirement of more than one surgical event. Certain growth factors aid in the development and vascularization of new bone, such as bone morphogenetic proteins (BMPs) and insulin-like growth factor I (IGF-1). We propose that nanoparticles of BMPs, IGL-1, and microorganism-specific antibiotics can be placed on the surface of intramedullary nails. These nanoparticles can be attached to various different polymeric materials such as poly(d,l-lactide), which is a biocompatible and biodegradable polymer, and can be positioned in several layers, to ensure controlled and systematic release. The placement of nanoparticles at the infection site alone will also ensure local delivery of the drugs only to the required areas. Moreover, these intramedullary nails will be useful for both infected non-unions and mal-unions. Over time, the nanoparticles will eradicate the infection and stimulate new healthy bone formation, whereas the intramedullary nail itself will provide constant stability and immobilization. This model provides new and revolutionary ideas for the development of individualized technologies in medicine.

CORR Insights®: Free Vascularized Fibular Grafting Improves Vascularity Compared With Core Decompression in Femoral Head Osteonecrosis: A Randomized Clinical Trial.

CORR Insights®: Free Vascularized Fibular Grafting Improves Vascularity Compared With Core Decompression in Femoral Head Osteonecrosis: A Randomized Clinical Trial.

Intercalary reconstructions after bone tumor resections: a review of treatments.

An intercalary reconstruction is defined as replacement of the diaphyseal portion of a long bone after segmental skeletal resection (diaphysectomy). Intercalary reconstructions typically result in superior function compared to other limb-sparing procedures as the patient's native joints above and below the reconstruction are left undisturbed. The most popular reconstructive options after segmental resection of a bone sarcoma include allografts, vascularized fibula graft, combined allograft and vascularized fibula, segmental endoprostheses, extracorporeal devitalized autograft, and segmental transport using the principles of distraction osteogenesis. This article aims to review the indications, techniques, limitations, pros and cons, and complications of the aforementioned methods of intercalary bone tumor resections and reconstructions in the context of the ever-growing, brave new field of limb-salvage surgery.

Long-Term Changes in Bone Height After Mandibular Reconstruction Using a Free Fibula Graft in an Elderly Population

This study evaluated short-term and long-term changes in bone height after mandibular reconstruction using an osteotomized fibula graft, with the aim of identifying factors associated with atrophy of the graft in an elderly population. This retrospective study involved patients who underwent mandibular reconstruction using a free vascularized fibula graft from 2005 through 2015 and had at least 12months of follow-up. Postoperative panoramic radiographs were used to measure bone height at standardized locations on each segment of the graft at 1year postoperatively and at later follow-up. The sample was composed of 30 patients (15 men, 15 women; mean age, 62.6years; age range, 50 to 80years). According to the HCL classification (H, hemimandibular segment including the condyle; C, central segment including both mandibular canine teeth; L, lateral segment without the condyle), mandibular defect types were L (n=19), LC (n=7), LCL (n=3), and H (n=1). There were 0 to 3 segmental osteotomies with the fibula graft. None of the patients received an osseointegrated dental implant during a mean follow-up of 4.0years (range, 1.5 to 9.7yr). All patients underwent reconstruction of the mandibular body, 10 of whom also underwent reconstruction of the mandibular ramus. Atrophy of the fibula graft was observed in 9.9 and 15.0% of the body segment and 5.9 and 6.6% of the ramal segment at 1year postoperatively and at later follow-up, respectively. Graft hypertrophy occurred in the ramal segment in 2 patients. Multivariate analysis showed a significantly higher rate of graft atrophy in women than in men at later follow-up (P=.033). Fibula grafts showed long-term stability, and in 2 cases even a gain in bone height, in this elderly population. Female gender was identified as a risk factor for atrophy of the fibula bone graft in the body segment of the reconstructed mandible.

Free Vascularized Fibular Grafting Improves Vascularity Compared With Core Decompression in Femoral Head Osteonecrosis: A Randomized Clinical Trial.

Management of osteonecrosis of the femoral head remains challenging. Core decompression and free vascularized fibular grafting are commonly used surgical procedures for treatment of osteonecrosis of the femoral head. Few studies, however, have compared these two procedures in a randomized controlled study, in terms of improved vascularity of the femoral head, progression of disease, or hip scores. QUESTION/PURPOSES: (1) What is the effect of core decompression and fibular grafting on vascularity of the femoral head as measured by single-photon emission CT (SPECT)/CT? (2) Does one of these two methods lead to greater progression of Association Research Circulation Osseous (ARCO) stage as determined by serial MRI? (3) What is the relationship between the change in vascularity of the femoral head and hip function as measured by the Harris hip score (HHS) and progression to THA as an endpoint? Arandomized controlled trial was performed between June 2010 and October 2012 at Zhongshan Hospital, Fudan University. During the study period, 51 patients who presented with ARCO Stages I to IIIB bilateral osteonecrosis were potentially eligible for inclusion, and 33 patients were identified as meeting the inclusion criteria and offered enrollment and randomization. Six patients declined to participate at the time of randomization, leaving a final sample of 27 participants (54 hips). Bilateral hips of each patient were randomly assigned to surgical options: one side was treated with core decompression and the contralateral side was concurrently treated with fibular grafting. SPECT/CT examinations were performed to quantify radionuclide uptake to evaluate vascularity of the femoral head before treatment and at 6 and 36 months after surgery. With the numbers available, we found no differences between the groups regarding vascularity at baseline (64% ± 8% core decompression-treated hips versus 64% ± 7% in the fibular-grafted hips; 95% CI, -5% to 5%; p = 0.90). MR images of the hips were obtained before surgery and at 6, 12, 24, and 36 months postoperatively and staged based on the ARCO classification. All patients were assessed clinically before treatment and followed up at 6, 12, 18, 24, 30, and 36 months after treatment using the HHS. We considered a difference in the HHS of 10 as the minimal clinically important difference (MCID). Patient progression to THA was defined as the endpoint for followup. Six patients (22%) were lost to followup. By SPECT/CT analysis, decompression-treated hips had lower vascularity than fibular-grafted hips at 6 months (68 % ± 6% versus 95% ± 5%; mean difference, -27%; 95% CI, -32% to -23%; p < 0.001) and 36 months (57% ± 4% versus 91% ± 3%; mean difference, -34%; 95% CI, -37% to -32%; p < 0.001). MRI analysis showed no differences between decompression-treated hips and fibular-grafted hips regarding ARCO stage at 12 months (p = 0.306) and 24 months (p = 0.06). Progression of ARCO staging was more severe in the decompression group than the fibular grafting group at 36 months (p = 0.027). The mean HHS was lower in the decompression group than in the fibular grafting group throughout the followup period, although these differences were at or below the MCID of 10 points early on. However, by 18 months, the scores favored fibular grafting (72 ± 4 versus 84 ± 4; mean difference, -13; 95% CI, -15 to -7; p < 0.001), a finding that was maintained at 24, 30, and 36 months. We found no differences between decompression-treated hips and fibular-grafted hips regarding progression to THA at 36 months (two of 21; p = 0.893). Hips that underwent a vascularized fibular grafting procedure fared better than hips receiving core decompression as measured by improved vascularity and less progression of osteonecrosis as measured by ARCO staging. The mean HHS of the fibular-grafted hips was better than that of the decompression-treated hips during the entire postoperative period, but the differences were modest early on, and for the early postoperative period the differences were unlikely to have been clinically important; by 18 months after surgery, the differences probably were clinically important. The mid-term outcomes associated with vascularized fibular grafting seen in our patients are associated with improvements in femoral head vascularity and the potential for bone revitalization. Level I, therapeutic study.

Free non-vascularized fibular graft for treatment of large bone defect around the elbow in pediatric patients.

Large bone defect is a challenging problem in orthopedics practice. Several methods are available for bridging of these bone defects, including cancellous bone graft, free vascularized fibula graft, and bone transport with external ring fixator. The aim of this study was to describe our experience in nine pediatric cases of free non-vascularized autogenous fibular strut bone graft in which large bone defect and bone loss of >7cm was caused by open fracture and infective nonunion around the elbow joint. To describe our experience in nine pediatric cases of free non-vascularized autogenous fibular strut bone graft in which large bone defect and bone loss of >7cm was caused by open fracture and infective nonunion around the elbow joint. This retrospective review was conducted in patients with large bone defect with bony gap >7cm. Time to union, range of motion, complications, Mayo Elbow Performance Score, and Foot and Ankle Disability Index (FADI) were recorded. The large bone defects included in this study were managed by free non-vascularized fibular strut bone grafts (FNVFG) that were harvested subperiosteally. Nine patients with a mean age of 11years (range: 6-17) underwent this procedure. Nine grafts (100%) united at both ends within an average of 9weeks (range: 8-14). Mean length of defect was 9.3cm (range: 8-13cm). Mean postoperative Mayo Elbow Performance Score was significantly higher than the mean preoperative score (98.33 vs. 64.44, respectively; p<0.001). Three fibulae were observed for hypertrophy. Mean Foot and Ankle Disability Index score was 100 both preoperatively and postoperatively in all patients. Free non-vascularized fibular graft is a simple procedure and a reliable method for bridging large bone defect or loss caused by open fracture and/or infection around the elbow in pediatric patients.

Gorham's disease in humerus treated with autogenous vascularized fibular graft.

Gorham's disease is a rare disorder of the bone characterized by progressive massive osteolysis. The pathophysiology is unknown, and diagnosis is often difficult. Most cases are often recognized retrospectively. There is no standardized treatment and management for Gorham's disease. We report a case of an 18-year-old male presenting with a pathologic fracture in the humerus shaft diagnosed with Gorham's disease. Patient was treated with autogenous vascularized fibular graft with wide excision and a 10 years followup after first surgery.

Three-stage treatment protocol for recalcitrant distal femoral nonunion.

In this study, we proposed a three-stage treatment protocol for recalcitrant distal femoral nonunion and aimed to analyze the clinical results. We retrospective reviewed 12 consecutive patients with recalcitrant distal femoral nonunion undergoing our three-stage treatment protocol from January 2010 to December 2014 in our institute. The three-stage treatment protocol comprised debridement of the nonunion site, lengthening to eliminate leg length discrepancy, deformity correction, stabilization with a locked plate, filling of the defect with cement spacer for inducing membrane formation, and bone reconstruction using a cancellous bone autograft (Masquelet technique) or free vascularized fibular bone graft. The bone union time, wound complication, lower limbs alignment, amount of lengthening, knee range of motion, and functional outcomes were evaluated. Osseous union with angular deformity <5° and leg length discrepancy <1cm were achieved in all the patients. The average amount of lengthening was 5.88cm (range 3.5-12cm). Excellent or good outcomes were obtained in 9 patients. Although the current study involved only a small number of patients and the intervention comprised three stages, we believe that such a protocol may be a valuable alternative for the treatment of recalcitrant distal femoral nonunion.

Management of Campanacci type III giant cell tumor

Objective: Giant cell tumor is an aggressive benign tumor of the bone, involving long bone. They are commonly present around knee joint. There are different treatment options and we assessed the treatment outcomes of various procedures. Methods: This case series was conducted using probability consecutive sampling technique in the Department Orthopedics Surgery, Combined Military Hospital, Lahore from December 2011 to March 2016 in a duration of five years four months. Our sample size was fifteen patients between 32 to 60 years of age with giant cell tumor. We included all patients with giant cell tumors newly diagnose on history, clinical examination, radiographs, magnetic resonance image (MRI) and bone biopsy. We excluded all patient with history of previous surgery, uncontrolled diabetes, chronic liver failure, chronic kidney disease and congestive heart failure. We managed all patients with various treatment option included resection arthrodesis with vascular fibular graft, mega prosthesis, and wide margin excision with bi-focal segment transport with external fixator device. We observed treatment effectiveness, limb length discrepancy, and post treatment complications. Our follow up period was four years. We followed all patients six monthly for one year and subsequently at one year. Results: There were 13 (86.7%) male and two (13.3%) females. Majority seven (46.67%) patients were present between 41 to 50 years of age with their mean±SD (30.66±13.87). Amongst three (20%) patients with involvement of proximal humerus, resection arthrodesis with vascular fibular graft was done, three (20%) patients with distal radius, two (66.66%) had resection arthrodesis with vascular fibular graft and one (33.34%) had mega prosthesis. Two (13.3%) had resection arthrodesis (50%) and mega prosthesis (50%). Majority five (33.3%) had proximal tibia involvement were treated with three (60%) resection arthrodesis and two (40%) with mega prosthesis. Among Two (13.3%) patients who had distal tibia involved were managed with wide margin excision, and bi focal segment transport with external fixator device. Out of the total 15 cases, nine (60%) had lower limb involvement and there was only one (11.11%) leg length discrepancy. Conclusion: We concluded from the study that management of giant cell tumors with mega prosthesis, segment trans port and resection with free fibular graft was equally good, but patient satisfaction was better in patients who had resection with mega prosthesis.

Early Vascularized Fibular Grafts in Infants with Congenital Pseudarthrosis.

Neurofibromatosis type I, also known as Von Recklinghausen disease, is one of the most common congenital disorders, with an incidence of 1 out of 3,000–4,000. It can be diagnosed on the basis of characteristic phenotypic manifestations, such as cafe-au-lait spots, axillary and inguinal freckling, neurofibromas, optic gliomas, Lisch nodules and distinctive osseous lesions. Osseous lesions occur in 2%–3% of neurofibromatosis type I cases, and are known to be caused by a lack of osteoblast function and the consolidation of osteoclast activity [1]. The most commonly affected region is the diaphysis of the tibia. Due to segmental disturbances in periosteal bone formation, anterior bowing occurs, and pathologic fractures eventually develop. In the first 2 years of life, pseudarthrosis may occur, which makes bone healing difficult due to persistent instability and progressive deformity in the bone. In patients with congenital pseudarthrosis, serious consequences such as amputation of the lower limb may be necessary if the condition is not adequately managed [2]. In this report, the authors describe the case of a vascularized fibular bone graft in a congenital pseudarthrosis patient.

Treatment of osteonecrosis of the femoral head with free vascularized fibular grafting: Results of 7.6-year follow-up

ObjectivesThe aim of this study was to determine long term follow up of the patients who had femoral head osteonecrosis and had been treated with free vascularized fibular grafting. Patients and methodsWe retrospectively reviewed 28 hips of 21 patients who had undergone free vascularized fibular grafting for the treatment of osteonecrosis of femoral head. There were 16 male and 5 female patients. The mean age of the patients at the time of surgery was 30.7 years (between 15 and 53 years). The mean follow-up time was 7.6 years (between 5 years and 9.2 years). ResultsDuring follow-up, one patient died because of leukemia, and one patient was lost. The remaining 26 hips of 19 patients were evaluated. According to the Ficat classification, at the time of surgery, 17 hips were in grade 2 and 9 hips were in grade 3. The post-operative Harris hip scores in grade II disease were excellent in 12 patients, good in 3 patients, and fair in 1 patient. In grade III disease, 1 patient was excellent, 5 patients were good, and 1 patient was fair. There was a significant increase in HHS scores (61 ± 9.7 vs 84 ± 17.8, p < 0.001). ConclusionFree vascularized fibular grafting yields extremely good results, particularly in pre-collapse stages of disease in young patients. The operation time does not mark increased if the surgical team is “familiar” with the procedure, and the residual fibular defect of the donor site does not impair the functions of daily living. Level of EvidenceLevel IV, Therapeutic study.